Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor.

Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

Urethral Obstruction in Women Prevalence: 2 - 29% of women with persistent LUTS Symptoms: – storage 29% – emptying 8% – both 63%

Diagnosis Urodynamics (synchronous pdet / Q) Cystoscopy

Urethral obstruction High detrusor pressure (pdet > 20 cm H 2 0) Low uroflow (Qmax < 12 ml/S)

Impaired Detrusor Contractility Weak & or poorly sustained detrusor contraction (pdet < 20 cm H 2 0) Low flow (Qmax < 12 ml/S)

Blaivas - Groutz Nomogram

Diagnosis ”…radiographic evidence of obstruction…in the presence of a sustained detrusor contraction.” No specific UDS criteria Obstructed women had: –lower Qmax –higher Pdet@Qmax –higher PVR 23% of 331 women were obstructed Nitti et al., 1999:

Etiology Groutz et al., 2000; Nitti et al., 1999 Prior surgery 14 - 30% Prolapse 29% Stricture 15% 1 O bladder neck obstruction 10 - 16% DESD 6% Learned Voiding Dysfunction 6 - 33% Urethral diverticulum 4%

Urethral Obstruction in women Anatomic Functional

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

MSCO High pressure Low flow

Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy

Pdet @ Qmax = 36cm H2O Qmax = 8.3ml/S

Pdet @ Qmax = 54 cm H2O Qmax = 2 ml/S,

FS pdet@Qmax = 68 cm H 2 0 Qmax = 5 ml/S Tic

JTJT JT pdet@Qmax = 80 cm H 2 0 Qmax = 5 ml/S

JTJT JT pdet@Qmax = 75 cm H 2 0 Qmax = 8 ml/S Urethral obstruction

RSN pdetmax = 90 cm H 2 0 Qmax = 7 ml/S

Anatomic Urethral Obstruction: Treatment Intermittent catheterization Surgery - depends on the cau se: –correct prolapse –sling incision / urethrolysis –urethral diverticulectomy

Surgical Rx of Stricture Urethral dilation Urethrotomy Urethroplasty

Buccal graft

2 Strss pdet@Qmax = 150 cm H20 Qmax = 1 ml/S

PS Involuntary detrusor contraction Involuntary sphincter contraction Obstruction due to sphincter contraction

CG Involuntary detrusor contraction Involuntary sphincter contraction Vesical neck obstruction

Detrusor contraction Sphincter contraction Low flow Obstruction by sphincter

Functional Urethral Obstruction: Treatment Primary vesical neck TUI / TUR of vesical neck ? Alpha adrenergic antagonists Neurogenic Intermittent catheterization +/- anticholinergics, Botox, Neuromodulation, enterocystoplasty Acquired behavior Bmod / biofeedback

Impaired Detrusor Contractility Low flow Weak or poorly sustained detrusor contraction Pressure flow criteria: –Qmax < 12 ml/s –Pdet@Qmax < 20 cm H2O –Wmax < 10 Groutz et al., 2000

amb pdetmax = 10 cm H 2 0) Qmax = 8 ml/S

Impaired Detrusor Contractility: Etiology Neurogenic –Thoracic, lumbar & sacral lesions –Diabetes mellitus Myogenic –Primary / idiopathc –Urethral obstruction –Bladder overdistension Urethral obstruction Post-surgical –Ischemia Groutz et al., 2000

Impaired Detrusor Contractility: Treatment Observation Double voiding Timed voiding Intermittent catheterization ? Medications –Cholinergic agonists –Alpha adrenergic antagonists Neuromodulation

Conclusion Urethral obstuction not uncommon Prevalence: 2 - 29% of pts with LUTS Symptoms – non-specific –irritative 29% –obstructive 8% –both 63% Diagnosis based on p/Q studies Rx based on underlying cause

Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor.

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Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor.

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Presentation on theme: "Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor."— Presentation transcript:

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